P.O. Box 5731 San Jose CA 95150
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________________________________________________ Address |
__________________________ Disability
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________________________________________________ City State Zip Code |
__________________________ Date of Birth
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Do you read Braille? Yes No |
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________________________________________________ Closest Relative or Friend |
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________________________________________________ Address |
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________________________________________________ City State Zip Code |
__________________________ Referred by
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_____________________ # Books Desired per Month |
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Subject/Author Preference
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Do you object to: Strong Language?_______ Explicit Sex?_______ Violence?_______
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FOR OFFICE USE ONLY
| Tapes Used In | # of People Served | ||||||
| ______ | Home (Individual) | _________________ | Outlet | ||||
| ______ | Special Ed Class | _________________ | |||||
| ______ | Chapter | _________________ | Day of Month | ||||
| Medical Verification Received | Catalog Sent | Number of Albums | |||||
| Date_______________________ | Date___________ | Reading Level | |||||
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AVI |
GOT |
HUM |
SCI |
SPY |
WHI |
J-BIO |
J-NAT |
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BIO |
HEA |
MYS |
SEA |
STL |
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J-CLA |
J-POE |
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CHR |
HER |
NAT |
SER |
STW |
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J-FIC |
J-POE |
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CLA |
HIS |
POE |
SHO |
TEC |
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J-HIS |
J-SER |
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FIC |
HOL |
REL |
SPA |
TRA |
C-FIC |
J-MYS |
J-SPO |
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FRE |
HLT |
ROM |
SPO |
WES |
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Comments_______________________________________________________________________________
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Prepared by (initials/date) ____________ Donor Perfect (initials/date) ____________
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